The SCR report found that health and social care professionals missed numerous opportunities to intervene to protect two-year-old Keanu, actions that could potentially have prevented his death at the hands of his mother in January 2011.
Reacting to the publication of the SCR on Thursday, NCB chief executive Hilary Emery said: “Our research has found that providing a trained advocate can make a real difference in ensuring a child's views are taken into account, and that everyone involved thinks and acts in a child-centred way.
“We urge government to look at the evidence and give every child access to an independent advocate, ensuring that lessons are learned from this [serious case] review.”
“Most importantly there needs to be a culture change from process-driven protocols which focus on bureaucratic procedures, to putting the rights and the needs of the child first.”
The British Association of Social Workers (BASW) said issues within Birmingham’s children’s services department must be addressed.
“There has been a culture of failure in Birmingham for many years now and it seems to have become ingrained,” Bridget Robb, BASW chief executive, said.
“The council has an old-fashioned and hierarchical culture, where scapegoating has been the norm and staff are reluctant to admit when mistakes are made and when they are struggling.
“Birmingham children’s services has had four management changes in four years and three department re-organisations. This constant instability is totally demoralising for social workers.
“It is time for an honest appraisal of child protection provision in the city, across all agencies.
“We want to see a management culture where frontline staff are supported to improve rather than a 'witch hunt' when things go wrong.”
Jo Cleary, chair of The College of Social Work, said the review highlighted the need for professionals to have responsibility for scrutinising and challenging each other’s assumptions, rather than simply sharing information.
“Professionals must be forever tenacious, inquisitive, and exceptionally skilled in working with children and families who are facing great problems and adversities in their lives,” she said.
Peter Wanless, chief executive of the NSPCC, said many of the lessons from Keanu's case had already come up “time and time again” in previous reports.
“We learn that a defenceless child was invisible, there was a lack of communication between agencies and that a manipulative parent was able to pull the wool over the eyes of professionals.
“It simply isn’t good enough to say that lessons will be learned from serious case reviews when all of the evidence before us suggests they are not. Lessons must translate to action on the frontline, well beyond Birmingham.”
He said that if professionals believe a child is at risk, they must “see it as their responsibility not simply to refer onwards but to do something decisive about it”.